APPLICATION FOR ADDITIONAL CLASSIFICATION - CONTRACTORAccess this form via website at: cca.hawaii.gov/pvl

READ FILING INSTRUCTIONS BEFORE COMPLETING THIS FORM.

FOR

OFF

ICE

USE

ON

LY

License No. Effective Date:

CLASS(ES):

Name of Applicant (First, Middle, Last OR name of Corporation/Partnership/JV/LLC/LLP):

Business/Residence Address (include apt. no., city, state & zip code):

Mailing Address (ONLY if different from above): Social Security No. OR Federal Employer I.D. No.:

Phone No. (days):

Check only one:

Individual (sole owner)

Corporation

Partnership

Joint Venture (JV)

Limited Liability Company (LLC)

Limited Liability Partnership (LLP)

Responsible Managing Employee (RME)

Class(es) Held:

License No.: Classification requesting (check):

"A" - General Engineering Contracting

"B" - General Building Contracting

"C" - Specialty Contracting. Indicate classification(s):

If applicant is a corporation, partnership, JV, LLC, LLP, provide:

Name of RME:

License No.:

If applicant is a Responsible Managing Employee (RME), provide:

Name of employing firm:

License No.:

Applicants for the C-19 ASBESTOS classification are required to submit approved proof of training. Refer to the information/instructions page.

CT-08 1117RAdd Class . . . . . . . . . . . . . . . . . . . . . 120 . . . . . . $50 Service Charge. . . . . . . . . . . . . . . . BCF . . . . . . $25

RME

APP

LICA

NTS

ON

LY

Employer (if self-employed, so state) Description of Work in DetailDates (mo/yr)

From To

Name:

Address:

Name:

Address:

(CONTINUED ON PAGE 2)

Print Name of Applicant: Date:RM

E A

PPLI

CAN

TS O

NLY

(con

t'd) List Names of five (5) major projects you have supervised in classification being requested. Attach additional sheets, if needed.

1)

4)

2)

3)

5)

Outline scope of work performed by you as a supervisor:

Affidavit of Applicant: I hereby certify that the statements, answers, and representations made in this application and in the documents attached are true and correct. I understand that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Section 710-1017, Sections 436B-19 and 444-17), Hawaii Revised Statutes. I further certify that I have read and will abide by the provisions of Hawaii Revised Statutes, Chapter 444 and Hawaii Administrative Rules, Chapter 77.

Applicant's Signature

Applicant's Title

Print Applicant's Name

Date

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This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

Release of Information to Third Party: To assist me in the licensing process, I hereby authorize DCCA's staff to release any and all information regarding my application (including, but not limited to application status) to the following third party:

Print name of Individual who is assisting you:

Name of Organization:

Signature of Applicant Date

FILING INSTRUCTIONS FOR: ADDITIONAL CLASS - CONTRACTORAccess this form via website at: cca.hawaii.gov/pvl

EXPERIENCE REQUIRED FOR RMEs APPLYING FOR ADDITIONAL CLASS(ES)

(CONTINUED ON NEXT PAGE)

A minimum of 4 years of supervisory experience within the past 10 years immediately preceding the filing of an application is required. Experience Certificates: Submit not less than 3 notarized certificates in support of supervisory experience with application. If applying for more than one classification, submit at least one experience certificate for each classification. (No two certificates in the same classification shall be from the same person.) Inform the person completing your experience certificate that they must describe in detail your experience performing on-site supervision and direction of employees in the classification you are applying for. Chronological History of Projects Form ("Project List"): Submit a Project List as documentation of the applicant's previous supervisory work experience. Use as many pages as necessary to verify your four (4) years of supervisory experience. The Project List may be duplicated and is available on the Contractor License Board's website at: http://cca.hawaii.gov/pvl/boards/contractor/application_publication. Click on "Chronological History of Projects Form". Submit a separate Project List for each classification the applicant intends to engage. Only include work experience performing on-site supervision and direction of employees. Please ensure that the Project List is filled out completely (provide information in each column of the form) and that it includes the following:

A description of your supervisory work experience performed in-house, with your own crew; and work or trades that were subcontracted to other contractors; and the means and methods of each project listed. The "Contract Amount" stated should be commensurate with information stated in the "Detailed Description of the Work You Supervised". The "Amount of Supervisory Experience" should only include the actual amount of time spent on-site supervising your own crew. Do not include time spent for design, ordering materials, scheduling of downtime for rain-outs or waiting for delivery of materials.

•

•

•

CONTRACTING ENTITY APPLYING FOR ADDITIONAL CLASS(ES)

RME/ENTITY APPOINTMENT Contracting Entity: Submit a letter confirming RME employment. RME: Submit a letter confirming employment with the contracting entity. IF the RME will be the RME for more than one contracting entity ("dual status"), submit documentation verifying one of the following requirements: 1) Common ownership if at least fifty-one percent of each contracting entity (Documentation of ownership includes, but is not limited to, tax returns (Schedule C or Form 1065 for LLCs, Schedule K-1 or Form 1125E for Corporations); Stock Certificates; Business Registration documents (for single member LLC's only); or Operating agreement.); 2) A contracting entity is a subsidiary or joint venture with the other contracting entity; 3) Direct immediate family relationship between the RME and the officers, directors, members, managers or partners of the other contracting entity; or 4) Direct immediate family relationship between the officers, directors, members, managers and partners of all contracting entities for which the individual acts as the RME.

BOARD'S ADDRESS

Mail to: Deliver to office location at:

Contractors License Board DCCA, PVL Licensing Branch P.O. Box 3469 Honolulu, HI 96801

335 Merchant Street, Room 301 Honolulu, HI 96813 Phone: (808) 586-3000

OR

Applications must be in our Honolulu office on or before the first Tuesday of the month prior to the scheduled meeting date. ALL required documents must be attached to this application at the time of filing. Incomplete/irregular applications will not be accepted. Failure to provide all requested information will delay the process of your application.

FILING DEADLINE

If applying from a specialty classification to an "A" (General Engineering) classification or a "B" (General Building) classification, submit a current (not more than a year old) COMPILED, REVIEWED, OR AUDITED financial statement accompanied by an independent accountant's report. The accountant must be a licensed or certified public accountant holding a current permit to practice. If the accountant is licensed in another state, provide a copy of the license. For COMPILED and REVIEWED financial statements: Applicant is required to sign the Board's Financial Statement Form whether or not your CPA uses the Board's Financial Statement Form. (NOT applicable to a RME applicant).

FINANCIAL STATEMENT

ATTACH fee of $50.00. Make check payable to COMMERCE & CONSUMER AFFAIRS. (check must be in U.S. dollars and be from a U.S. financial institution.) Note: One of the numerous legal requirements that you must meet in order for your new license to be issued is the payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us for your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service charge shall be assessed for payments that are dishonored for any reason. If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing must be directed to the agency that denied your application, and must be made within 60 days of notification that your application for a license has been denied.

FEE

(CONTINUED ON NEXT PAGE)

ASBESTOS CONTRACTOR RMEs applying to do asbestos application, enclosure, removal, encapsulation, renovation, repair, demolition or other disturbances of friable asbestos or asbestos containing material shall meet all requirements with the exception of experience. In lieu of experience, the RME shall submit proof of successful completion of a 4-day Environmental Protection Agency (EPA) or Board approved asbestos training course within two years prior to filing the application.

Applicants who possess licensed experience in another state should provide proof of licensure, but will still be required to submit not less than 3 certificates in support of supervisory experience and the Project List. Certain technical training may be approved as acceptable experience, but in no case shall the training count for more than one year of experience.

EXPERIENCE REQUIRED FOR RMEs APPLYING FOR ADDITIONAL CLASS(ES) cont'd

ABANDONMENT OF APPLICATION

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to provide evidence of continued efforts include but is not limited to: (1) failure to submit any required information and documents requested by the licensing authority within two consecutive years from the last date the documents and information were requested, or (2) failure to complete any additional requirements for licensure that remain after approval of your application, such as attempting to complete an exam requirement, within two consecutive years from the date your application was approved, or (3) failure to provide the licensing authority with any written communication during two consecutive years indicating that you are attempting to complete the licensing process. If an application is deemed abandoned the applicant shall be required to reapply for licensure and comply with the licensing requirements in effect at the time of the reapplication.

ATTENTION: CONTRACTORS APPLYING FOR ELECTRICAL OR PLUMBING RELATED CLASSIFICATIONS

Please be advised that in order to perform electrical or plumbing work in Hawaii, an individual must be licensed as an electrician (e.g. ES or EJ) or plumber (e.g. PM or PJ). IF the contracting entity's responsible managing employee, which includes a sole proprietor, is not licensed as an electrician or plumber in accordance with HRS Chapter 448E, the contracting entity must employ a licensed electrician or plumber in accordance with HRS Chapter 448E to actually perform the electrical or plumbing work. (Refer to Hawaii Revised Statutes, Section 444-9.5 and Chapter 448E.) YOU MAY NEED THIS TYPE OF LICENSE TO GET A BUILDING PERMIT.

If an agency or individual is assisting you with the licensure process, we will not be able to release any information to them unless you provide us with authorization. If you wish to do so, please complete the portion on Release of Information to Third Party, sign and date it.

RELEASE OF INFORMATION

The contractors licensing examinations are given by a professional testing service, Prometric. Applicants, upon approval by the Board, will be provided with examination registration forms. Applicants must mail the registration forms, together with the appropriate examination fees, directly to Prometric. Questions regarding the examination and study material should be directed to the testing service at (808) 261-8182 or visit their website at: www.prometric.com/hawaii.

EXAMINATION

EXPERIENCE CERTIFICATE - CONTRACTOR'S LICENSEAccess this form via website at: cca.hawaii.gov/pvl

IMPORTANT!! READ "COMPLETION OF THIS EXPERIENCE CERTIFICATION" (page 3) BEFORE COMPLETING THIS CERTIFICATE.

THIS SECTION TO BE COMPLETED BY THE APPLICANT:Name of Applicant: (First, Middle, Last)

Classification requesting (check one only):

THIS SECTION TO BE COMPLETED BY THE PERSON WHO WILL CERTIFY TO THE APPLICANT'S EXPERIENCE:

Indicate your BUSINESS RELATIONSHIPto the applicant:

EMPLOYER

SUPERVISOR

RME Lic. #

FELLOW EMPLOYEE

JOURNEYMAN

OTHER (specify):

Classifications held:

From: To:

Employment Dates (mo/yr):

Length of service:

Yrs. mos.

Dates applicant has supervised:From: To:

TOTAL TIME:

FULL-TIME

PART-TIME -Hours per week, if

part-time

Indicate LEVEL applicant worked at:

JOURNEYMAN

FOREMAN

SUPERVISOR

CONTRACTOR

OTHER (specify):

Did the applicant demonstrate a level of knowledge and skill expected of a journeyman or better in the craft(s) of trade(s) listed above? (Check your answer.)

YES NO

Did the applicant demonstrate a history of honesty, truthfulness, financial integrity and fair dealing?

YES NO

(Refer to the Board's definitions of each of the above levels on the "Completion of this Experience Certification" page.)

DESCRIBE IN DETAIL THE APPLICANTS EXPERIENCE PERFORMING ON-SITE SUPERVISION AND DIRECTION OF EMPLOYEES IN THE CLASSIFICATION INDICATED ABOVE (i.e. General Engineering, General Building, etc.):

(SIGNATURE REQUIRED ON PAGE 2 IN FRONT OF NOTARY)

CT-03 1017R

A - General Engineering B - General Building C -

Print Name of Applicant: Date:

Section 444-30, HRS, of the contractors license law provides that: Any person or his agent who files with the Contractors License Board any notice, statement, or other document required under the provisions of the contractors license law, which is false or untrue or contains any material misstatement of fact is guilty of a misdemeanor. Certification of Person Completing this form:

I, hereby certify that I have personally known the person

named as applicant above; that I have direct knowledge of the applicant's supervisory experience which I have listed; and, all other statements and answers given here are true and correct.

Date:

(Print name of certifier)

Signature of the Certifier in front of Notary Public

Subscribed and sworn to before me this day of A.D. 20 .

Notary Signature:

Notary Public, State of:

My commission expires:

Print Name:

Doc. Date: No. of Pages:

Notary Name: Circuit Court:

Doc. Description

Notary Signature:

Date:

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

-2-

DO NOT SEND THIS FORM TO THE CONTRACTORS LICENSE BOARD. INSTEAD, PLEASE RETURN IT TO THE APPLICANT SO THE APPLICANT CAN ATTACH IT TO THE APPLICATION.

Print Your Name:

Address of Certifier:

Contractor's Lic. No. ENTITY: Contractor's Lic. No. RME:

Licensed Classifications of Certifier: State:

Home Phone No.: Business Phone No.:( () )

-3-

COMPLETION OF THIS EXPERIENCE CERTIFICATION

The applicant must detail four full years of supervisory experience within the past 10 years, in the classification the applicant is applying for, at the level of a Journeyman, Foreman, Supervisor, or Contractor (see definitions below). The applicant must also submit certificates to support this experience. The certificates must be completed by a qualified and responsible person; that is, by an employer, fellow employee, or journeyman who has DIRECT KNOWLEDGE of the applicant's experience. DIRECT KNOWLEDGE is knowledge of the truth in regard to a particular fact, which is original, and does not depend on information or hearsay. The applicant is requesting that you complete this form to certify as to your DIRECT KNOWLEDGE of the applicant's experience. As a qualified and responsible person you must certify that the applicant demonstrated a level of knowledge and skill expected of a journeyman or better in the classification for which the application is being made by describing in detail the applicant's experience performing on-site supervision and direction of employees in the classification the applicant is applying for. JOURNEYMAN is an experienced worker in the trade who is fully qualified as opposed to a trainee, and is able to perform the trade without supervision. FOREMAN/SUPERVISOR is a person who has the knowledge and skill of a journeyman and also directly supervises the physical construction. CONTRACTOR is one or more of the following: 1) a currently licensed Hawaii contractor 2) a formerly licensed Hawaii contractor 3) a person listed under "Personnel of Record" on the license application of a currently licensed Hawaii contractor 4) an out-of-state contractor who held a license in that state A Contractor is a person who has the skills necessary to manage the daily activities of a construction business, including field supervision. Your cooperation is earnestly solicited so that the Contractors License Board can determine whether this applicant has the experience necessary to become a capable and qualified contractor.

IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it is suggested that you keep a copy of the certificate you complete.

DO NOT SEND THIS FORM TO THE CONTRACTORS LICENSE BOARD. INSTEAD, PLEASE RETURN IT TO THE APPLICANT SO THE APPLICANT CAN ATTACH IT TO THE APPLICATION.

CONTRACTORS FINANCIAL STATEMENT(Prescribed Form)

Financial Statement as of , 20 (not more than one year old) is for:

Name of Applicant:(Sole Proprietor, Corporation, Partnership, Joint Venture, LLC, LLP)

Note: The name listed on this financial statement must be exactly the same name listed on your application under "Name of Applicant".

CURRENT ASSETS:

ASSETS:

Cash (include checking account) . . . . . . $

Savings Account. . . . . . . . . . . . . . . . . .

Time certificates (within 1 year). . . .

Deposit with bids . . . . . . . . . . . . . . . .

TOTAL CASH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Accounts receivable (completed contracts). . . . . . . . . . . .

$

Earned estimated & retainage (uncompleted contracts)

Other accounts receivable. . . . . . . . . . . . . . . . . . . . . . . . . . .

Work in progress (unbilled). . . . . . . . . . . . . . . . . . . . . . . . . .

Notes receivable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Stocks and bonds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Life insurance (cash value). . . . . . . . . . . . . . . . . . . . . . . . . . .

Other current assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL CURRENT ASSETS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OTHER ASSETS:

$

Material in stock (not included in any items above). . . . . $

Inventory or other materials. . . . . . . . . . . . . . . . . . . . . . . . .

Other assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL OTHER ASSETS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

FIXED ASSETS:

Equipment at net book value. . . . . . . . . . . . . . . . . . . . . . .

Real estate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Furniture and fixtures at net book value. . . . . . . . . . . . .

Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other fixed assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL FIXED ASSETS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

$

TOTAL ASSETS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CT-02 1117R

(SIGNATURE OF APPLICANT REQUIRED ON PAGE 2)

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

SHALL BE PREPARED AND SIGNED BY A LICENSED PUBLIC ACCOUNTANT (PA) OR CERTIFIED PUBLIC ACCOUNTANT (CPA) HOLDING A CURRENT PERMIT TO PRACTICE. IF LICENSED IN ANOTHER STATE, PROVIDE COPY OF A CURRENT LICENSE. Note: Financial Statements prepared by bookkeepers and tax preparers are not acceptable.

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PRINT NAME:

SIGNATURE OF C.P.A. or P.A.:

STATE:

LICENSE NO.:

See accompanying independent accountant's report. The undersigned has no interest in the above enterprise.

TITLE (owner, president, etc.):

SIGNATURE OF APPLICANT:

I hereby certify as owner, officer, partner, manager, member or R.M.E. that the statements contained on this statement are true and correct. I certify that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Sec. 710-1017, Sections 436B-19, and 444-17, Hawaii Revised Statutes).

For compiled and reviewed financial statements: This statement must be signed, whether CPA uses this form or his own.

$TOTAL LIABILITIES AND NET WORTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$TOTAL NET WORTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Surplus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Capital stock (if corporation, show shares authorized, issued-par value). . . . . . . . . . . . . . . . . . . . . . . . . $

NET WORTH:

LIABILITIES:

Name of Applicant:CURRENT LIABILITIES:

Notes payable (due within one year):

To banks regular . . . . . . . . . . . . . . . . .

To material men . . . . . . . . . . . . . . . . .

To other (exclusive of Equipment). . . .

TOTAL NOTES PAYABLE. . . . . . . . . . . . . . . . . . . . . . . . . .

$

$

Accounts payable:

Subcontractors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Material men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL ACCOUNTS PAYABLE. . . . . . . . . . . . . . . . . . . . . $

Current maturities (long-term debt). . . . . . . . . . . . . . . . . . . $

Accrued payrolls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federal and state income tax. . . . . . . . . . . . . . . . . . . . . . . .Payroll taxes (including F.I.C.A. S.U.I. and income taxes withheld). . . . . . . . . . . . . . . . . . . . . .

Other accrued taxes, interest, etc. . . . . . . . . . . . . . . . . . . .

Encumbrances on equipment (due within 1 year). . . . .

Other Current Liabilities (specify):

$TOTAL CURRENT LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LONG-TERM LIABILITIES:

Long-term debt (less portion due within one year). . . . .

Encumbrances on equipment (due after 1 year). . . . . .

$

Encumbrances on real estate. . . . . . . . . . . . . . . . . . . . . . . .

Billings in excess of cost on uncompleted contracts. .

Other long-term liabilities (specify):

TOTAL LONG-TERM LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

TOTAL LIABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

(Sole Proprietor, Corporation, Partnership, Joint Venture, LLC, LLP)

Financial Statement as of , 20 (not more than one year old) is for:

THE STATEMENT BELOW MUST BE SIGNED BY THE APPLICANT, WHETHER CPA USES THIS FORM OR HIS OWN. FINANCIAL STATEMENT MUST BE COMPILED, REVIEWED OR AUDITED AND ACCOMPANIED BY AN INDEPENDENT ACCOUNTANT'S REPORT.